When every second counts

MUHC specialized Trauma Centre improving mortality stats
Dr. Tarek Razek
Dr. Tarek Razek, MUHC chief of Trauma of the adult sites, believes most "accidents" are preventable. (Photo: Pierre Dubois)

For most people, the term "car accident" is an innocent turn of phrase. Not so for Dr. Tarek Razek, Chief of Trauma at the McGill University Health Centre (MUHC), who tenses the minute he hears those words. "A trauma specialist will never say car accident. It's car crash," he insists. "Very few car crashes are accidents, meaning almost all of them could have been prevented with proper education and greater awareness of issues like drinking and driving."

Razek's passion on the subject is easy to understand. As chief of one of only four tertiary trauma centres in Quebec, Razek is responsible for making sure that victims of the most devastating car crashes on the island of Montreal immediately receive top-notch care from a coordinated team of specialists. Treating more than 9,000 trauma patients a year who are victims not only of crashes but of falls, workplace accidents, assaults and anything else that results in severe injury, the MUHC is, according to Razek, one of the busiest trauma centres in the country.

"Most people don't realize how devastating trauma is," he says. "To put it in perspective, trauma is the number one cause of death for people under 49 in Canada, and is by far the leading cause of death in children. In the population as a whole, it's the cause of the most years of life lost, more than cancer, heart disease or any other condition. With those statistics, it's incredibly important that we offer world-class trauma care and that we keep working to find more effective ways of treating, and preventing, multi-system injuries."

A huge step forward in trauma treatment took place in 1993, when a major reorganization in the way serious injuries were treated in Quebec led to the creation of four tertiary trauma centres. Before then, trauma victims were simply taken to the nearest emergency room, regardless of how well or poorly equipped that hospital might be to treat them. "Most trauma victims require wellstocked blood banks and experts in orthopedics, neurosurgery, plastics and just about every other specialty you can imagine," Razek says. "In the old days, not many places had access to a neurosurgeon at 3 a.m., making it very difficult to deal with cases that arrived in the middle of the night. Not having the right people in place put a huge burden on emergency room staff and facilities."

In the 1980s, physicians and surgeons across North America began to reevaluate how the most severe traumas were triaged and treated, using as their model the experiences of army medics and surgeons who had worked on the battlefields of Vietnam and Korea. They soon realized that trauma victims had the best chance of survival if they were treated at a specialized trauma centre, even if this meant being transported a short or long distance away. In Montreal, it was surgeons at the Montreal General Hospital who were at the vanguard of bringing this important movement to Quebec. "The General had a long history of expertise in treating severe traumatic injury," Razek says. "Following on this tradition, Dr. David Mulder was instrumental in establishing Quebec's four tertiary trauma centres and ensuring that the General, which later became part of the MUHC, was one of them."

Today, as soon as emergency responders arrive at the scene of a major trauma, the victims are evaluated according to an objective scale to determine if their injuries warrant transport to a tertiary trauma centre. If they do, the responders call the nearest centre and ask that the trauma team be assembled. In a significant number of cases, it is Razek and his colleagues at the MUHC who receive the call. "The most important member of the trauma team - the quarterback, as it were - is the Trauma Team Leader (TTL)," Razek explains. "The TTL is paged by the ER staff when a trauma is on the way, and it's his or her responsibility to arrive at the hospital in no more than 20 minutes. The TTL is an expert in trauma resuscitation and can be a surgeon, emergency physician, or anaesthesiologist .

Once at the hospital, the TTL notifies the blood bank and assembles an interdisciplinary team that includes nurses, senior surgical residents, respiratory therapists and social workers. In most cases, all of this takes place before the patient arrives. "Having a specialized team means that even the most complex trauma case won't deplete the resources we have to deal with our normal emergency caseload," Razek says. With the arrival of the patient, the TTL's evaluates and prioritizes his or her injuries and pages the necessary additional specialists (plastic surgeons, neurosurgeons, orthopedic surgeons and so on) in the appropriate sequence. "It isn't unusual for trauma patients to have injuries to every major system in their body," says Razek. "According to protocol, the TTL decides what needs to be done first and also performs resuscitation and emergency procedures to manage patients as they await further treatment."

How well does this system work? Razek is visibly enthusiastic as he cites the statistics. "In 1993, before the trauma centres were up and running, studies showed that the mortality rate from the most severe types of traumas was 50 percent, in other words, one in two of those patients didn't survive." In 1998, the studies were repeated and the figure had dropped to 18 percent, and in 2002, once the system had matured even further, mortality had dropped to an astonishing 8.9 percent. "This kind of radical improvement is almost unheard of in medicine," Razek says. "The only explanation is that specialized trauma centres like ours at the MUHC make an incredible difference in how well we can treat the most severely injured patients."

The key to a trauma centre's success is a wellorchestrated multidisciplinary team that is able to respond quickly. Every member must be highly qualified not just in her own specialty, but in the particulars of trauma care. According to Razek, the MUHC is in many ways an ideal environment for this system. "We have an excellent group of specialists who are used to working in a collaborative and cross-disciplinary environment," he says. "Our surgical residents are very well trained and our nurses are skilled and dedicated. Trauma care uses a lot of resources at every level, from the specialized neurosurgeon on call nights and weekends to the housekeeping staff that makes sure we have sterile places to work. We're very lucky to have all of the pieces in this complicated puzzle in place." The addition of two new surgical recruits, Dr. Paola Fata and Dr. Kosar Khwaja, to this team means that we will have assembled one of the strongest groups in the country.

Asked what the MUHC trauma team does best, Razek grins, "Actually, we're pretty good at just about everything."

In fact, the MUHC's trauma team is so respected that they are currently partnering with nongovernment organizations (NGOs) to train doctors and nurses in Ethiopia, Tanzania and Uganda. In an interesting reversal of learning from Vietnam medics whose experiences in battle informed modern trauma care, the MUHC also trains medics in the Canadian military in how best to treat traumatic battlefield injuries.

With such a successful track record, how do Razek and his colleagues plan to improve trauma care at the MUHC? First, he is enthusiastic about the improvements to the ER and trauma facilities that will come with the redevelopment of the MUHC's Mountain campus. "We're already thrilled with the recent renovations to our emergency room," he says, referring to improvements that were funded in large part through gifts to the Best Care for Life campaign. "When the redevelopment is complete, we'll see a smoother flow of patients through all of the service areas, from radiology and intensive care to operating rooms and recovery areas."

Razek would also like to see improvements in the way patients are treated before they arrive at the hospital. "We'd prefer to have a lot more paramedics and first responders in the field," he says. "Our emergency responders do excellent work, but a fully trained paramedic can administer more sophisticated care in those critical first hours before a patient gets to the hospital."

Which brings us back to car crashes. Accidental or not, patients unfortunate enough to find themselves in Dr. Razek's trauma bay can at least be assured that they are in very good hands indeed.

Reprinted from MUHC Health Perspectives.

 

trauma


TRAUMA VITALS

  • Trauma is the leading killer of people between the ages of 1 and 49
  • Montreal has the highest rate of pedestrian injuries in Canada
  • Strong leadership and a longstanding culture of trauma care at the MGH led the way in 1993 to the regionalization of trauma care in Quebec, and MGH became one of four of the province's government-designated trauma centres
  • When the MGH trauma system is activated, the Trauma Team Leader must respond within 20 minutes. A team of nursing, anaesthesia, respiratory therapists, blood bank, orderlies and clerks descend into the Trauma Bay of the Emergency Room.
  • Since the creation of the Adult Trauma Program, mortality rates in trauma in Quebec have dropped from 50 per cent in 1993 to 8.9 per cent in 2002